Nurses Notes Essay
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Writing stays with you throughout your entire life, though you may not believe so. Hidden in your thoughts about your future career is the idea that writing will be part of your profession. After doing extensive research, I now realize how much writing will be involved with my chosen profession, a registered nurse. Writing in nursing can range from short, concise works to long, detailed, complex works. Writing as a nurse contains nurse’s notes, documentation, written reports, health records, flowcharts, care-plans, narratives, and if desired, professional journals for publication.
The position within in the field also plays a role with the amount of writing needed to be done. The head of a department takes part in a lot more writing than a nurse. A head of a department holds a variety of duties when it comes to writing such as: staff proposals, budget proposals, department operations, policies and procedures, and protocols. A nurse must be able to follow the basic writing standards: writing clear, concise, and grammatically correct sentences, use proper punctuation, and demonstrate critical thought.
Nurses are also expected to learn how to present information succinctly with their work being accessible to anyone who may read it. Nurses aim to write work that can be used in both clinical aspects of discipline and research. The field of nursing requires a nurse to be able to write swiftly and accurately. Nurses must also always be prepared to define their recorded information and writing. Records must be clear, concise, complete and accurate. The cliché that is universally known, the job is not complete until the paperwork is completed is more true in health care than in any other profession, referring to the fact that a lot of writing is done in this workforce.
Types of Writing: Nursing as a profession contains many different types of writing. Nurse’s notes are records that nurses who directly care for the patient, continuously record information. This includes the patient’s symptoms, medications given, and scheduled procedures or activities.
Documentation reflects the care the care the nurse has or has not provided to the patient. Documentation is the nurse’s only form of legal proof that they did or did not do something for the patient. Nurse’s look at documentation as important as the actual care they are providing for their patient. Hands-on care and documentation carries equal importance in the eyes of a registered nurse. Documentation then becomes art of the patient’s medical record after the patient is either discharged or no longer living.
Written reports are needed when the care of a patient is given over to another nurse. I interviewed Sharon Doll, a registered nurse at Glendive Medical Center who states that these written reports are very rare. “It is highly unlikely that you as a registered nurse will have to give the care of your patient over to another nurse.” (Personal interview, November 23, 2012)
Health records, or medical records, consist of the accumulation of nurse’s notes. The records are held on file at the hospital and are referred to when needed. Health records consist of prescriptions prescribed to the patient, x-ray results, test results, reports, blood type, allergies and other important information about the patient that the care providers may need to be aware of. Recently, health records have transferred to being electronic, taking away from the writing perspective. Assessment check-boxes go hand-in-hand with health records as well, which are the summary of the symptoms of the patient.
Flowcharts simply show the process that has been taken while caring for patients. They show the sequence in which the patient has followed. This is a concise review of the patient’s history and the care that was provided.
Care-plans outline the nursing care that is to be provided to the patient. It is a set of actions that the nurse will take to provide the necessary care for the patient in hopes of full recovery. A care-plan consists of three parts: definition of the problem, intervention and/or solutions, and the evaluation of success or intervention and/or solution. Many times, care-plans are set out by the doctor because the doctor is not as available as the nurse. Care-plans are usually completed day-by-day and sort of run on a schedule.
Narratives are important in nursing communication and important in the aspect of capturing the patient’s history and also the treatment they received. Narratives use standard abbreviations, are not written in first person, instead they refer to themselves as “the nurse”, and finally, rely on the communication with others.
Professional journals for publication are optional for nurses but are quite popular. Journals are a compiled of the nurse’s experience, clinical practices, and their theoretical approaches and/or opinions. Nurses write journals to inform their audience, primarily formed of nursing students. Nurse’s journals give other people a first-hand look at their point of view and their job.
If a nurse rises to the head of a department, he/she will face more writing than that of a registered nurse. Staff proposals and budget proposals are simply directed within the department. A staff proposal consists of the duties of the staff and the expectations they are held to. Budget proposals consist of the budget throughout the department and how it will be distributed. Department operations are the operations the department can fulfill. These include the day-to-day functioning of the department. Policies and procedures review the policies by which the employees must follow and the procedures they take before handling care for a patient. Finally, protocols refer to the steps of the procedures and experiments that are conducted by the department. Reflection:
Montana State University prepares students to be successful in their chosen field. MSU offers Writing 101 and also University Seminar that covers the writing aspect. I think the preparation of MSU for nursing students and writing is sufficient due to the fact that the majority of the junior year in the pre-nursing major simply consists of all nursing classes. These classes will also review all aspects of nursing, including the writing that a registered nurse will complete within the profession. Conclusion:
Overall, I was unaware of all the writing that was needed in the profession of a registered nurse. I did not think that I would do more than simply taking nurse’s notes. With these findings, I am very grateful for the writing courses offered at Montana State University.